Comparative Study of Surgical Therapy Vs Other Modalities of Therapy for Pseudocyst of Pancreas

Gowthaman, A (2013) Comparative Study of Surgical Therapy Vs Other Modalities of Therapy for Pseudocyst of Pancreas. Masters thesis, Madras Medical College, Chennai.


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INTRODUCTION: Pancreatic pseudocysts are encapsulated collections of necrotic tissue, old blood and secretions walled off by granulation tissue from the pancreas. The prefix “pseudo” is used to emphasize the fact that these collections frequently have no true capsule and that the cyst wall is made up of adjacent viscera such as the stomach and / or colon. The pseudocysts are the most common complications following pancreatic inflammation both acute and chronic. They also constitute the most frequently encountered cystic lesions of the pancreas others being the cystic neoplasms. For the pseudocysts<5cms there are chances of autoregression. The pseudocysts present clinically as epigastric pain, abdominal masses to jaundice. The laboratory findings are not much of use in the diagnosis of these pseudocysts. It is radiology which helps in the diagnosis of the pseudocysts with the help of USG, CT scan, MRI, etc. These investigations govern the therapeutic procedures to be carried out. Essentially the treatment for pseudocyst is multimodal one. The treatment team for pseudocysts includes radiologists, endotherapists and surgeons. The radiologists by way of guided per-cutaneous techniques for aspiration/drainage to the therapeutic embolization of bleeding aneurysms and the endotherapists by way of various endoscopic drainage procedures contribute to the team. The various diagnostic and therapeutic procedures available for intervention are also studied and effectiveness of USG guided aspiration as the primary modality of treatment as compared to conventional surgeries is also studied. AIMS AND OBJECTIVES: 1. To compare USG guided per-cutaneous aspiration with the surgical treatment options available for pseudocyst of pancreas in terms of patient and physician factors. 2. To compare the various surgical drainage procedures that has been employed for the treatment of pseudocysts of pancreas. 3. To compare the results of endoscopic drainage vs surgical procedures employed for drainage of pancreatic pseudocysts. MATERIALS & METHODS: The study is a Prospective Observational study conducted at Rajiv Gandhi Government General Hospital from July 2012 to December 2012. 50 adult patients with symptomatic pancreatic pseudocyst were included in the study. Pseudocysts with greater than or equal to 6 weeks duration or cyst wall of 6mm thick or more will be involved in the study. Children and traumatic pseudocysts, and Pseudocysts <6 weeks duration and wall thickness of < 6 mm were excluded from the study. Patients were subjected to baseline investigation`s (Biochemistry, Haemogram, and Chest Skiagram). This was then followed up by specific investigations like serum amylase, serum lipase, serum LDH, serum Calcium, liver function test. USG – Abdomen and CT – Abdomen were done to all to identify the morphology, size, extent, shape of the pseudocyst, the relation to the pancreas and its accessibility from Gastrointestinal tract. MRCP & ERCP was done to identify the pancreatic duct morphology, communication to the pseudocyst cavity, abnormalities and variations in minor and major draining systems, & to detect biliary pathology. Each patient was then classified according to the type of pseudocyst and the mode of therapeutic intervention was decided. RESULTS: A total of 50 patients were included in the study. All the patients were available till the end of the study and for follow up. Out of 50 patients the cause of pancreatic pseudocyst was found to be alcohol consumption in 80% & biliary causes in 14%. The most common indication for intervention was persistent pain (60%) and Gastric outlet obstruction (14%). The type of intervention was chosen based on the physical state of the patient as well as location and type of the pseudocyst. USG Guided drainage was done in 14%, Endoscopic drainage - Transpapillary 18% & Transgastric 6% and Surgical drainage procedure – cystogastrostomy - 36% & cystojejunostomy 26%. The complication rates in different procedures were as follows:- USG guided drainage - 4 out of 7 patients (57.1%), Endoscopic drainage - 4 out of 12 patients (33.3%), Surgical drainage - 9 out 31 patients (29%), Among surgical modalities the complication rates of cystogastrostomy was 27.8% against cystojejunostomy - 30.8%. The most common complication was recurrence of the pseudocyst that was found in 6 out of 50 patients - 12%. Bleeding, fistula formation, sepsis, pancreatitis, bowel injury were among the other complications. Elective surgery was done after a mean time gap of 45 days after diagnosing the pseudocyst. One patient who had a recurrence after USG guided aspiration was again intervened with surgical approach. Post operatively repeat imaging showed incomplete resolution or recurrence of the pseudocyst in 12% patients. CONCLUSIONS: Surgical and endoscopic interventions for pancreatic pseudocysts are equally effective and safe with a less important role for percutaneous drainage. Eventhough various minimally invasive procedures have come up for the treatment of pseudocysts, till date surgery remains the gold standard. Endoscopic drainage has nearly the same success and complication rates as against surgery. So endoscopic therapy should be considered for appropriate patients. Moreover even if the endoscopic intervention fails there is always the second choice of a surgical option left open. At the same time USG guided percutaneous intervention has to be reserved for very sick and morbid patients as an emergency life saving procedure only, it is not to be used as a definitive procedure. Among surgical methods both cystogastrostomy and cystojejunostomy are equally effective if individualized according to the patient factors.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Surgical Therapy ; Other Modalities of Therapy ; Pseudocyst of Pancreas ; Comparative Study.
Subjects: MEDICAL > General Surgery
Depositing User: Devi S
Date Deposited: 26 Mar 2018 13:34
Last Modified: 26 Mar 2018 13:34

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